PROJECT SUMMARY Though cancer diagnosis and treatment remain national health priorities, recent gains in cancer care have not been deployed to the benefit of U.S. populations equally, particularly for cancers for which surgery is a primary component of treatment. Rural areas have higher rates of cancer mortality than their urban counterparts, and cancers for which effective screening exists tend to be more prevalent in rural populations. Rural patients undergo fewer cancer-directed surgeries for some cancers and have worse surgical outcomes than urban patients. Surgical disparities could be exacerbated by the continued closure of rural hospitals, potentially limiting access to cancer surgery and specialist care for rural patients. Since 2004, over 400 rural hospitals have closed their doors, and another 430 hospitals are at high risk of closure. Though rural-urban disparities may result directly from these closures and the ensuing lack of access to surgical care, they may also be a consequence of a general lack of economic and social opportunities. In this proposed research, we will explore disparities in access to, treatment for, and outcomes of cancer care using Medicare claims data. While differences in rural-urban outcomes have been examined, the intersectionality of rurality with other sociodemographic characteristics (including racial/ethnic disparities and income) has not been examined for cancers for which surgery is a primary treatment. We will 1) describe this intersectionality in disparities in surgical care for lung, pancreatic, colon, and rectal cancers, 2) estimate the impact of hospital closure on disparities in access, treatment, and outcomes for patients with cancer, and 3) assess the potential effects of policy solutions in maintaining access to care for rural patients, including telemedicine and Medicaid expansion. This proposed work will give us an overarching view into the landscape, current challenges, and potential solutions for rural surgical cancer care. This work will allow us to better understand disparities in care for rural underserved populations, and how geography intersects with race, ethnicity, and socioeconomic status to exacerbate differences in access, quality, and outcomes.